Clinico-genetic model to predict methotrexate intolerance in rheumatoid arthritis

Frequency of Helicobacter pylori in Patients With Rheumatoid Arthritis Whose Methotrexate Was Stopped Due to Gastrointestinal Intolerance

OBJECTIVE

The aims of this study were to compare the frequency of Helicobacter pylori between patients with rheumatoid arthritis (RA) with and without methotrexate (MTX)-related gastrointestinal system (GIS) intolerance, and to demonstrate the associated factors with such intolerance.

METHODS

The data of 9756 patients with RA who presented between January 2011 and December 2020 were evaluated. Methotrexate-related GIS intolerance was defined as the discontinuation of MTX owing to the dyspeptic symptoms despite supportive measures and was detected in 1742 (31.3%) patients among 5572 MTX users. A total of 390 patients with and without intolerance who had at least 1 gastroscopic evaluation were included in the final analyses. The demographic, clinical, laboratory, and pathologic characteristics of patients with and without MTX-related GIS intolerance were compared. To determine the associated factors with MTX-related GIS intolerance, logistic regression analysis was performed.

RESULTS

Of 390 patients, 160 (41.0%) patients had MTX-related GIS intolerance. According to the pathology results, the presence of H. pylori , inflammation, and activity were significantly higher in patients with MTX-related GIS intolerance ( p < 0.001 for each comparison). In multivariable logistic regression analysis, the use of biologic disease-modifying antirheumatic drugs (DMARDs) or targeted synthetic DMARDs was found to be an independently associated factor for MTX-related GIS intolerance (odds ratio [OR], 3.03 for model 1; OR, 3.02 for model 2) in addition to H. pylori presence (OR, 9.13 for model 1; OR, 5.71 for model 2).

CONCLUSIONS

In this study, we found that the presence of H. pylori and the use of biologic or targeted synthetic DMARDs were associated with MTX-related GIS intolerance.

Tapering of disease-modifying antirheumatic drugs: an overview for daily practice

In this Review, we discuss the possibility of drug tapering in patients with rheumatoid arthritis in remission or low disease activity, for glucocorticoids and disease-modifying antirheumatic drugs. We review international guidelines and recommendations, as well as remaining uncertainties, and provide an overview of the current literature. Three strategies of tapering are discussed: (1) tapering by discontinuation of one of the drugs in combination therapy regimens, (2) tapering by reducing the dose of one of the drugs in combination therapy regimens, and (3) tapering by dose reduction of monotherapy with disease-modifying antirheumatic drugs. We discuss the outcomes and robustness of evidence of trials and observational cohorts, and we give a trajectory for further research and drug tapering in daily practice.

Assessing methotrexate intolerance and its prevalence in rheumatoid arthritis: Development and validation of the MISA questionnaire

OBJECTIVE

Methotrexate (MTX) intolerance refers to unpleasant symptoms that accompany use of MTX. Although a validated questionnaire on MTX intolerance exists for children with juvenile idiopathic arthritis, it is lacking for adult rheumatoid arthritis (RA) patients.

METHODS

A 10-item questionnaire called Methotrexate Intolerance and Severity assessment in Adults (MISA) was developed to assess MTX intolerance. On receiver operating characteristic analysis, its predictive ability was compared to Methotrexate Intolerance Severity Score (MISS), a validated questionnaire for children. Subsequently, prevalence and associations of intolerance were assessed in 414 RA patients. After 1 year, discontinuation of MTX was compared between patients with and without MTX intolerance.

RESULTS

MISA score had a good predictive ability (area under the curve [AUC] of 0.904), with sensitivity and specificity of 91.4% and 84.3% (cut-off ≥1) to correctly classify MTX intolerance and was better than MISS score (AUC of 0.823). Among 414 RA patients, 159 (38.4%) had MTX intolerance, with common symptoms being nausea, lethargy, irritability and loss of appetite. On multivariable analysis, age (odds ratio 0.972) and body mass index (odds ratio 1.061) were significant predictors of MTX intolerance. At 1 year, a higher proportion of patients with intolerance than without intolerance had discontinued MTX (odds ratio 2.4, P = 0.02). To classify severity of intolerance, another score, MISA-cross-product, was developed and validated, with an AUC of 0.899.

CONCLUSIONS

The newly developed MISA questionnaire and score had good predictive ability to diagnose MTX intolerance. Intolerance to MTX was common, being found in one-third of RA patients. Patients with intolerance were twice more likely to discontinue MTX at 1 year.

Abatacept in rheumatoid arthritis-associated interstitial lung disease: short-term outcomes and predictors of progression

INTRODUCTION

Interstitial lung disease in rheumatoid arthritis (RA-ILD) is an extra-articular involvement that impairs the prognosis and for which there is still no well-coded treatment. The aim of this study was to evaluate abatacept (ABA) effectiveness and safety in patients with RA-ILD.

METHODS

RA-ILD patients who started ABA treatment were consecutively enrolled. Chest high-resolution computed tomography (HRCT), clinical, laboratory and respiratory function variables were collected at baseline and after 18 months of ABA treatment. HRCT abnormalities were evaluated using a computer-aided method (CaM). ABA response was established based on the change in the percentage of fibrosis evaluated at HRCT-CaM, dividing patients into "worsened" (progression ≥ 15%), "improved" (reduction ≥ 15%), and "stable" (changes within the 15% range). The multivariate regression model was used to assess the associations between RA characteristics and ABA response.

RESULTS

Forty-four patients (81% women, mean age 59.1 ± 8.0, mean disease duration of 7.5 ± 3.1 years) were studied. Five patients (11.4%) showed RA-ILD progression, 32 patients (72.6%) were considered stable, and 7 patients (16.0%) showed an RA-ILD improvement. The proportion of current smokers was significantly different between "worsened" patients, respect to those defined as "improved/stable" (p = 0.01). Current smoking habit (p = 0.005) and concomitant methotrexate treatment (p = 0.0078) were the two variables related to RA-ILD progression in multivariate regression analysis.

CONCLUSION

Treatment with ABA is associated with a RA-ILD stability or improvement in the 88.6% of patients. Current smoking habit and concomitant treatment with methotrexate are the modifiable factors associated with RA-ILD worsening. Key Points • Abatacept plays a favourable role in the control of RA-ILD, with a significant worsening in only 11.4% of patients during a 18-month follow-up period. • The predictive variables related to RA-ILD progression during abatacept therapy are the concomitant treatment with methotrexate and current smoking habit.